Form 0920-24CX Eligibility Screener

Form Approved

OMB No. 0920-1154

Exp. Date: 3/31/26

Screening/Eligibility Form for Focus Groups

(form to be read and conducted by recruiter)

1. Are you comfortable speaking and reading in English?

   1. Yes [ELIGIBLE; CONTINUE]

   2. No [INELIGIBLE; STOP]

   3. Don’t Know [INELIGIBLE; STOP]

2. Do you visit freshwater bodies, such as lakes or rivers, in the summer?

   1. Yes [ELIGIBLE; CONTINUE]

   2. No [INELIGIBLE; STOP]

3. On average, how often do you visit freshwater bodies in the summer?

   1. at least once per month [ELIGIBLE; CONTINUE]

   2. less than once per month [INELIGIBLE; STOP]

4. What is your age? [Record age.]

   1. Age 18+ years [ELIGIBLE; CONTINUE]

   2. Age <18 years [INELIGIBLE; STOP]

   3. Refused [INELIGIBLE; STOP]

5. Have you participated in any focus group, interview, telephone survey, or online survey in which you were asked your opinions about a product, a service, or advertising within the past six months?

   1. No [ELIGIBLE; CONTINUE]

   2. Yes [INELIGIBLE; STOP]

6. Have you participated in any research studies about water safety in the past 4 years?

   1. No [ELIGIBLE; CONTINUE]

   2. Yes [INELIGIBLE; STOP]

7. Have you worked in any of the following areas within the past 2 years?

• market research

• graphic design or website design

• advertising or public relations

• media (TV/radio/newspapers/magazines/social media)

• healthcare (e.g., doctor, nurse, pharmacist, dietician, etc.)

• federal government

1. No [ELIGIBLE; CONTINUE]

2. Yes [INELIGIBLE; STOP]

8. Have you ever heard of harmful algal blooms (HABs)?

   1. Yes [ELIGIBLE; CONTINUE]

   2. No [ELIGIBLE; SKIP TO QUESTION 10]

   3. Don’t Know [ELIGIBLE; SKIP TO QUESTION 10]

9. Does your job involve knowing about harmful algal blooms (HABs)?

   1. Yes [INELIGIBLE; STOP]

   2. No [ELIGIBLE; CONTINUE ]

   3. Don’t Know [ELIGIBLE; CONTINUE]

The discussion we would like you to participate in will take place on the computer.  The next few questions will involve technology – please answer these questions considering the computer you will be using to join the focus group. 

10. Do you currently have access to high-speed (at least 1.5Mbps) internet – again considering the location and computer you will be joining the discussion from?

[    ] Yes

[    ] No TERMINATE

11. What type of computer will you be using?

[ ] Laptop

[ ] Desktop

[ ] I do not have access to a laptop or desktop -TERMINATE

12. Do you currently have a working webcam on your computer (whether built in or plug in)?

[ ] Yes – Built In

[ ] Yes – External

[  ] No- TERMINATE

13. Do you have access to an active email account?

[    ] Yes – RECORD CAREFULLY ________________________________________

[    ] No TERMINATE

This account is where we will send your confirmation email with important instructions on how to join the session.

14. What internet browser do you use (e.g., Internet Explorer, Chrome, Safari, Firefox, Edge)?   ________________________________________

ELIGIBILITY CHECK:

□ Yes □ No

Date: Initials:

CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-1154).

Highly Sensitive/Any User (No encryption)

Highly Sensitive/Any User (No encryption)

Highly Sensitive/Any User (No encryption)

Highly Sensitive/Any User (No encryption)